Gov. Hochul at a Pride parade (photo: Don Pollard/Office of Governor Kathy Hochul)
As we celebrate Pride Month, the New York State Department of Health (DOH) has just released a sobering report revealing the startling health disparities faced by LGBTQI+ New Yorkers. We need continued action to advance equity in our health-care system.
Yet the DOH plans to proceed with a Medicaid pharmacy benefit carve-out that’s a legacy of the Cuomo era and would disrupt health care for millions of Medicaid recipients, many of whom are LGBTQI+. It also could lead to the closure of the community clinics that serve them—all in the name of generating dubious savings.
Proceeding with the Medicaid pharmacy carve-out would make it more difficult for LGBTQI+ New Yorkers to access the life-saving care they need. New York State’s own data recognizes long-standing inequalities in health care delivery and health outcomes, particularly among Latino and other communities of color, as well as low-income communities.
The new DOH report shows that LGBTQI+ New Yorkers are more likely to face frequent mental distress, depression, and other complex health issues—but less likely to have access to health care.
DOH HIV surveillance data further demonstrates that LGBTQI+ New Yorkers, communities of color, and low-income communities continue to bear the brunt of the HIV epidemic, despite advances in effective HIV treatment and prevention: They have higher infection rates, are less likely to be engaged in treatment to become virally suppressed, and those who are at high risk for HIV have lower rates of PrEP uptake.
One effective way to tackle these troubling health outcomes has been Medicaid Special Needs Health Plans (SNPs). SNPs help people living with HIV and AIDS access life-extending medications, and they reduce hospital use associated with unmanaged HIV.
A large portion of SNP participants are communities of color and people of LGBTQI+ experience—in particular, transgender and gender-nonconforming (TGNC) New Yorkers. SNPs work closely with their members, pharmacies, and culturally competent providers, and they have expert pharmacists trained in LGBTQI+ health care.
Currently, Medicaid beneficiaries receive their pharmacy benefit through their SNP. The carve-out would irreparably disrupt their access to pharmacy support by removing it from SNPs and instead pooling all Medicaid beneficiaries in the State under a single Pharmacy Benefit Manager (PBM).
Approximately 6 million New Yorkers would lose access to specialized pharmacists, including those with expertise in HIV, mental health, and gender-affirming care. The pharmacy carve-out contradicts Governor Hochul’s and the DOH’s actions to address HIV and health care disparities, which are outlined in the New York State AIDS Institute Director’s call to action.
The Governor has the power to repeal the carve-out, and we call on her to do so immediately.
We only have to look to California to see how catastrophic following through on this short-sighted policy would be. After a similar pharmacy carve-out was implemented in California earlier this year, thousands of Medicaid beneficiaries went weeks without their medications. Providers faced authorization delays, making it harder to treat complex conditions. Call centers were overwhelmed.
Magellan Health, the company California made its pharmacy benefit manager, lacked experience in LGBTQI+ health issues, leading to long wait times and delays in accessing care. Concerningly, Magellan would also handle New York’s pharmacy benefits if the carve-out is implemented here next year.
The state argues that this model will save money. However, studies indicate it will actually cost taxpayers billions in the long run. California’s experience clearly demonstrates that the carve-out will cause treatment delays that will cost New York more money, not to mention higher emergency room and inpatient costs.
For the LGBTQI+ community, accessing care is already difficult enough. LGBTQI+ people routinely face discrimination and harassment in medical settings. TGNC people often have to educate their health-care providers about transgender health issues, due to a lack of provider training.
The pharmacy carve-out would worsen New York’s health disparities for LGBTQI+ communities and communities of color. It’s easy to see why so many New Yorkers aren’t engaged in care. If we force people to confront another obstacle in our state’s health care system, who knows how many will drop out of care for good?
New York State needs to expand access to care for LGBTQI+ people, including gender-affirming care, HIV treatment, and mental health care. The pharmacy carve-out takes us in the wrong direction: It will cost the state more money and needlessly place millions of lives at risk.
Let’s not create more barriers for those already facing grave health disparities, and instead make it easier for all New Yorkers to live their healthiest, most authentic lives. We ask Governor Hochul to take action today and repeal the Medicaid pharmacy benefit carve-out.
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Kishani C. Moreno, MA, is Interim Chief Executive Officer and Chief Operating Officer at GMHC. On Twitter @GMHC.
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Rethinking economic development (photo: Edwin J. Torres/Mayor's Office)
The COVID-19 pandemic has profoundly altered state economies. At this point, it’s clear that some of the changes will last, with significant implications for how governments should think about the future. State economic development agencies are tasked with building that future and they need new approaches to address these changes.
In January 2021, with the assistance of staff from the New York Empire State Development Corporation, we began a process of reviewing research literature and reports and interviewing experts across the country to develop a new approach to state economic development in the post-pandemic environment.
The result is a report, issued June 16 and titled Strategies for Building Inclusive and Progressive State Economies in the Post-COVID Era, that discusses how existing state policy tools can be adapted, reoriented, and improved to build a more equitable and prosperous society.
Our report emphasizes there are three key imperatives that must inform a new approach to economic development.
Confronting Systemic Inequality
The most important lesson of COVID-19 is that we must do more to confront the enormous systemic inequities that continue to plague our society. According to the CDC, Black and Hispanic Americans were roughly three times as likely to be hospitalized and twice as likely to die from covid as white Americans.
At the same time, the economic impact of COVID-19 fell particularly hard on people of color and lower-income communities, in part because they are over-represented in the most impacted industries, such as food and hospitality.
No longer can government policy, including the billions spent on economic development, be detached from a central focus on bridging inequities and addressing structural barriers to success. An estimate from the Economic Policy Institute found that rising inequality has slowed U.S. economic growth in aggregate demand by two to four percentage points in recent years as the share of income has shifted from lower income, lower-saving households to higher income, higher-saving households. Addressing structural inequality is not only a moral imperative – it is an economic imperative.
Embracing New Models of Work
Covid changed how many people work and live and those changes are proving to be long lasting, not transitory. State government must help lay the groundwork for new “spoke and hub” models of work that involve better transit-based, sustainable infrastructure.
In the past, jobs that required high levels of interaction with peers were mainly located in dense urban centers and some of their employees traded off higher housing costs and smaller spaces for shorter commutes. An infrastructure of in-person services – from restaurants and bars to shoe repair and dry-cleaning shops – grew up around the businesses. Service firm employees often struggled to find affordable housing within reasonable distance of their jobs.
In the post-covid world, many people who can do their jobs all or in part remotely will choose to live further away from the urban core. For example, the commuting hub around New York City will expand substantially – perhaps by up to 100 miles, encompassing all of Long Island, the Hudson River Valley nearly up to Albany, and much of the way to Binghamton.
Leveraging Increased Federal Spending
Policy levers on the federal and state level that were previously politically untenable or considered too costly – ranging from eviction moratoria to economic stimulus – have been utilized.
The influx of federal funding, including from the $2.2 trillion Coronavirus Aid, Relief, and Economic Security Act (CARES Act) passed in March 2020, the $1.9 trillion American Rescue Plan Act passed in March 2021, and the $1.2 trillion infrastructure bill passed in November 2021, will have long-term implications. These new funding streams, if used strategically and effectively, have the potential to make a lasting impact on state economies.
Based on these themes, our report offers a clear thesis for change over the next five years focused on five key areas and objectives:
1. Economic Development Policy: Reorient states’ economic development tools to focus on strategic, data-driven investments.
2. Workforce Development: Align workforce development investments with business needs and future job opportunities.
3. Affordable Communities: Reimagine cities and new commuter hubs as affordable, sustainable communities where people can live and work.
4. New Business Development: Support business expansion and leverage universities to drive new R&D ecosystems.
5. 21st Century Digital Infrastructure: Lead on digital infrastructure to lay the foundation for economic growth in the 21st century.
The post-covid world poses new challenges for state economies. Without further action, remote work is likely to exacerbate already unacceptable economic inequalities. Existing neighborhoods, communities, and transportation networks may be a poor fit for the new economic environment. State economic development agencies will be expected to respond, and if they do so by using the tools of the past, they are unlikely to achieve the results needed in this unexpected future.
The good news is that there has been a wealth of research and an explosion of data that economic development agencies can use to improve and target their practices.
State economic policy has the tools to focus on projects that produce not only more but better jobs for disadvantaged communities, to leverage data that enables the promotion of efficient workforce and infrastructure development policy, and to emphasize building a more equitable and flexible labor force and economy. It can, and must, shift from an emphasis on individual firms and projects to a strategy that emphasizes the development of human capital and infrastructure.
Our hope is that our report can serve as a blueprint for states at a moment when we have the potential to produce the most progressive economic change since the great depression.
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Sherry Glied is Dean of New York University's Robert F. Wagner Graduate School of Public Service. Carol Kellermann was president of Citizens Budget Commission from 2008 through 2018.
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Gov. Hochul signs gun control legislation (photo: Don Pollard/Governor's Office)
The U.S. Supreme Court, in the June 23 decision in New York State Rifle and Pistol Association et al v. Bruen, Superintendent of the New York State Police et al, invalidated New York’s historic “concealed carry” law, sometimes called the “Sullivan Law” after its lead sponsor, State Senator Timothy Sullivan.
1911: Rising public concern with gun violence
It is helpful to recall why the Sullivan Law was passed in the first place.
That 1911 law provided that: ”Any person over the age of sixteen years, who shall have in his possession in any city, village or town of this state, any pistol, revolver, or other firearm of a size which may be concealed upon the person, without a written license therefor, issued by a police magistrate or any such city or village, or by a justice of the peace of such town, or in such manner as shall be prescribed by ordinance in such city, village or town, shall be guilty of a misdemeanor” (NY Laws of 1911, Ch.. 195).
Rising public concern with gun violence in the early 20th century led to the law. In August 1910, New York City Mayor William J. Gaynor, waiting to board a passenger ship in Hoboken, NJ, was shot by an aggrieved New York City dock worker who had been fired from his job. Gaynor was grievously wounded but survived.
In January 1911, famous novelist David Graham Phillips was shot dead near Gramercy Park by a deranged man who believed Phillips used one of the man’s family members as a character in one of his novels. The shooter then killed himself.
The Gaynor and Phillips shootings sparked public outrage. But it was a rising tide of shootings using concealed weapons in New York City streets that led to legislative action.
Senator Sullivan explained that “gun toters” fell into three categories. The first was professional criminals. The second was deranged people. His proposed law would help in those areas.
But he was most concerned with a third category, “young fellows who carry guns around in their pockets all the time not because they are murderers or criminals but because the other fellows do it and they want to be able to protect themselves. [T]hose boys aren’t all bad but…just carrying their guns around makes them itch to use them.”
Opponents of the bill objected that law-abiding citizens needed firearms to defend themselves and their homes. You cannot force a criminal to get a license to use a gun, others asserted. Guns would flow into New York from other states with lax gun restrictions, rendering it hard to enforce.
Other critics said the law could be used disproportionately against newly-arrived immigrants and other minority groups. Still other skeptics warned that the law might enable unscrupulous police officers to frame suspects by planting guns on them at the time of arrest.
But press and public opinion strongly favored the measure. The city coroner’s office issued reports highlighting deaths from handguns. “A rigid law making it difficult to buy revolvers would be the means of saving hundreds of lives,” said the office’s January 1911 report. New York County District Attorney Charles Whitman told reporters that “carrying a weapon is an invitation to a crime. Reduce the weapons carried and you reduce the crimes of violence.” Civic and commercial groups endorsed Sullivan’s proposal.
Democrats held a majority in the State Legislature. Sullivan was a Democrat and the New York City Tammany Hall Democratic Party organization backed his proposal. But legislators from both parties, sensing the public demand for action, jumped on board. The bill garnered 46 of 51 votes in the Senate and 148 out of 150 in the Assembly. Democratic governor John A. Dix quickly signed it into law. It took effect on August 31, 1911.
New York amended the law in 1913 to clarify the licensing standard: magistrates could “issue to [a] person a license to have and carry concealed a pistol or revolver without regard to employment or place of possessing such weapon” only if that person proved “good moral character” and “proper cause” (NY Laws of 1913, Ch. 608).
The procedures have been revised since then but, as the Supreme Court’s opinion in Rifle and Pistol Association v. Bruen notes, “today’s licensing scheme largely tracks that of the early 1900s.”
After More Than a Century, the Law Falls
The Sullivan Law has been challenged in state and federal courts several times but, until now, has been deemed constitutional.
In the new Supreme Court decision overturning the law, Justice Clarence Thomas notes that “No New York State statute defines ‘proper cause.’” He offers a lengthy discussion of historical precedents and previous court decisions. He notes that “at the end of this long journey through the Anglo-American history of public carry, we conclude that respondents have not met their burden to identify an American tradition justifying the State’s proper-cause requirement. The Second Amendment guaranteed to ‘all Americans’ the right to bear commonly used arms in public subject to certain reasonable, well-defined restrictions.”
The opinion concludes that “New York’s proper-cause requirement violates the Fourteenth Amendment in that it prevents law-abiding citizens with ordinary self-defense needs from exercising their right to keep and bear arms.”
This is a 6-3 decision, with the dissenters citing their own view of historical precedent and statistics about people killed by handguns every year.
The decision is a reminder that courts play a powerful role in our society. “We are under a constitution but the constitution is what the judges say it is,” Charles Evans Hughes, Chief Justice 1930-1941 remarked early in his career. That may be an overstatement but it indicates the courts’ strong authority.
What happens next?
The Supreme Court decision reversed a state Court of Appeals opinion that had supported the law. The decision ends with these words: “We therefore reverse the judgment of the Court of Appeals and remand the case for further proceedings consistent with this opinion.”
It is not certain what that Court will do; “…further proceedings consistent with this opinion” seems like a fairly broad concept.
But attention has already shifted to the Legislature and Governor Kathy Hochul. Ironically, the decision comes shortly after the Legislature enacted other gun control measures. Now, as in 1911, the Legislature is led by New York City Democrats (and a Senate majority leader from the suburbs) and the governor hails from upstate (John Dix was from Glens Falls, Kathy Hochul is from Buffalo).
As Justice Stephen Breyer noted in his dissent in the new Supreme Court decision:
What kinds of firearm regulations should a State adopt? Different States might choose to answer that question differently. They may face different challenges because of their different geographic and demographic compositions. A State like New York, which must account for the roughly 8.5 million people living in the 303 square miles of New York City, might choose to adopt different (and stricter) firearms regulations than States like Montana or Wyoming, which do not contain any city remotely comparable in terms of population or density….For a variety of reasons, States may also be willing to tolerate different degrees of risk and therefore choose to balance the competing benefits and dangers of firearms differently.
Governor Hochul has already announced a special session of the Legislature for this week to deal with the issue. History may in a sense repeat itself as New York, 111 years after its first concealed carry law, again takes the lead in searching for a solution that addresses public safety concerns and also recognizes and abides by constitutional protections and guarantees as outlined by the court.
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Bruce W. Dearstyne is a historian in Albany, NY. SUNY Press recently published the second edition of his book The Spirit of New York: Defining Events in the Empire State's History and his new book The Crucible of Public Policy: New York Courts in the Progressive Era.
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